INTERNATIONAL EPIDEMIOLOGICAL STUDY ON MICROBIOLOGY OF UNCOMPLICATED UTIs. PROSPECTIVE MULTICENTER, OBSERVATIONAL EPIDEMIOLOGICAL SURVEY.

Presentación del tema: "INTERNATIONAL EPIDEMIOLOGICAL STUDY ON MICROBIOLOGY OF UNCOMPLICATED UTIs. PROSPECTIVE MULTICENTER, OBSERVATIONAL EPIDEMIOLOGICAL SURVEY."— Transcripción de la presentación:

1 INTERNATIONAL EPIDEMIOLOGICAL STUDY ON MICROBIOLOGY OF UNCOMPLICATED UTIs. PROSPECTIVE MULTICENTER, OBSERVATIONAL EPIDEMIOLOGICAL SURVEY

2 SURVEILLANCE STUDIES ON THE EPIDEMIOLOGY OF RESISTANCE BECOME INSTRUMENTAL IN GUIDING EMPIRIC THERAPY OF UNCOMPLICATED UTIs

3 ARESC STUDY September 2003 June 2006

4 ARESC STUDY END-POINTS PRIMARY: Prevalence and susceptibility of pathogens in uncomplicated lower, community acquired UTIs SECONDARY: Prevalence and susceptibility of pathogens in patients with recurrent UTIs and during pregnancy

5 Female patients aged between 18 and 65 years Pregnant women included Symptoms of uncomplicated UTI Positive culture defined as a sample with  10 4 cfu/ml in midstream urine Recurrent uncomplicated UTI (defined as  3 episodes of UTI in the last year ) included Informed consent INCLUSION CRITERIA

6 ARESC STUDY 4264 patients enrolled 3018 bacterial pathogens analyzed

7 AUSTRIA: 3 BRASIL: 6 FRANCE:10 GERMANY: 8 HUNGARY: 5 ITALY: 6 NETHERLANDS: 2 POLAND: 6 RUSSIA: 10 SPAIN: 9 SITES DISTRIBUTION RUSSIA BRASIL SPAIN GERMANY ITALY AUSTRIA HUNGARY FRANCE THE NETHERLANDS POLAND 10 COUNTRIES 65 CENTERS

8 Patient characteristics Mean: 38.2 years Mean: 38,0 years SPAIN GLOBAL

9 Patient characteristics Mean: 38.2 years Mean: 38,0 years SPAIN GLOBAL

10 Patient Characteristics SPAIN GLOBAL

11 Patient Symptoms SPAIN GLOBAL

12 TYPES OF INFECTION SPAIN GLOBAL

13 TYPES OF INFECTION SPAIN GLOBAL

14 URINEANALYSIS SPAIN GLOBAL

15 URINEANALYSIS SPAIN GLOBAL

16 PATHOGENS TESTED CountryStrain N° Spain650 Brasil506 France488 Russia416 Italy329 Germany317 Poland119 Austria91 Hungary66 The Netherlands36 Total3018

17 AETIOLOGY of uncomplicated UTIs E.coli 76.7% 3018 uropathogens Other ENT: Klebsiella spp., Enterobacter spp., Citrobacter spp., H.alvei, M.morganii, Pantoea spp., Serratia spp., Salmonella spp. Other not-ENT: P.aeruginosa, B.cepacia Other G+: Enterococcus spp., S.aureus, Staphylococcus coagulase -, Streptococcus spp.

18 AETIOLOGY of uncomplicated UTIs (Spain E.coli 79.2% 650 uropathogens Other ENT: Klebsiella spp., Enterobacter spp., Citrobacter spp., H.alvei, M.morganii, Pantoea spp., Serratia spp., Salmonella spp. Other not-ENT: P.aeruginosa, B.cepacia Other G+: Enterococcus spp., S.aureus, Staphylococcus coagulase -, Streptococcus spp.

19 AETIOLOGY age groups *Enterobacter spp., Citrobacter spp., Klebsiella spp., H.alvei, M.morganii, Pantoea spp., Serratia spp., Salmonella spp. °P.aeruginosa, B.cepacia, Enterococcus spp., S.aureus, Staphylococcus coagulase -, Streptococcus spp.

20 Country %N° France83.8409 The Netherlands80.629 Spain79.2515 Hungary78.852 Germany76.7243 Poland75.690 Brasil73.9374 Italy72.6239 Russia72.6302 Austria68.162 Total76.72315 E.coli INCIDENCE

21 Influence of patient’ characteristics on E. Coli incidence On the other parameters as: Menopause, Sexual intercouse, Constipation, Kind of sample or Fever: No significant differences were observed Mean 76,7

22 Antibiotic % SI + R Fosfomycin 98.21.8 Mecillinam 95.94.1 Nitrofurantoin 95.24.8 Ciprofloxacin 91.38.7 Amoxi/clav. 81.918.2 Nalidixic acid 81.418.6 Cefuroxime axetil 81.019.0 Co-trimoxazole 70.629.4 Ampicillin 45.154.9 2315 E.coli GLOBAL SUSCEPTIBILITY PATTERNS

23 Antibiotic MIC (mg/L)% RangeMIC 50 MIC 90 SIR Fosfomycin<1-5122897.31.51.2 Mecillinam 1280.5494.21.74.1 Nitrofurantoin<0.5-256163294.23.72.1 Amoxi/clav.0.25/0.12- 128/648/416/877.718.63.7 Cefuroxime axetil0.25->1284875.322.91.8 Ciprofloxacin 16<0.015888.10.211.7 Nalidixic acid 1284>12873.6/26.4 Co-trimoxazole 16/3040.5/9.5>16/30466.2/33.8 Ampicillin1->128>128 35.34.760.0 E.coli SUSCEPTIBILITY PATTERNS (650) Spain

24 Antibiotic % SI + R Ciprofloxacin94.45.6 Amoxi/clav.90.79.3 Fosfomycin*87.912.1 Nalidixic acid82.217.7 Cefuroxime axetil78.521.5 Co-trimoxazole76.623.4 Nitrofurantoin17.882.2 Ampicillin0100 107 K.pneumoniae GLOBAL SUSCEPTIBILITY PATTERNS * : presumptive breakpoint (S< 64 mg/L)

25 Antibiotic % SI + R Amoxi/clav.94.25.8 Cefuroxime axetil93.36.7 Ciprofloxacin90.49.6 Fosfomycin * 86.413.6 Nalidixic acid78.821.2 Ampicillin67.332.7 Co-trimoxazole62.537.5 Nitrofurantoin0100 104 P.mirabilis GLOBAL SUSCEPTIBILITY PATTERNS * : presumptive breakpoint (S< 64 mg/L)

26 Antibiotic % SI + R Amoxi/clav.1000 Ciprofloxacin99.10.9 Nitrofurantoin98.11.9 Cefuroxime axetil96.33.7 Co-trimoxazole89.710.3 Ampicillin63.636.4 Fosfomycin *0100 102 S.saprophyticus GLOBAL SUSCEPTIBILITY PATTERNS * : presumptive breakpoint (S< 64 mg/L)

27 ARESC STUDY: CONCLUSIONS E.coli has been confirmed to represent the most common agent of uncomplicated UTIs AMPICILLIN and SXT most affected by resistance Agents used specifically in UTIs - FOSFOMYCIN - MECILLINAM - NITROFURANTOIN exhibited low levels of R in all participating countries both in recurrent and not recurrent UTIs For FQ and other β-lactams local epidemiological data are mandatory for a correct empiric therapy (R rates >10-20%)

28 First line therapy of uncomplicated UTI with fosfomycin: CM advantages Appropriate spectrum Minimal resistance in the primary pathogen Resistant clones crippled Overcomes resistance to unrelated drugs

29 INITIAL EMPIRIC THERAPY: FOSFOMYCIN TROMETAMOL: 1d NITROFURANTOIN: 5-7d PIVMECILLINAM: 7d Only after consideration of LOCAL Resistance rates: Co-trimoxazole (3 d) Trimethoprim (5-7 d) Fluoroquinolones (3 d) Naber et al., 2006 EUROPEAN ASSOCIATION OF UROLOGY 2006 GUIDELINES FOR TREATMENT OF UNCOMPLICATED UTIs

30

31 Objetivos de la guía

32 Pacientes diana: criterios de inclusión El paciente diana es toda mujer afecta de cistitis no complicada, definida como aquella infección urinaria que ocurre en personas que tienen un tracto urinario normal, sin alteraciones funcionales o anatómicas, sin historia reciente de instrumentación (sondaje, uretrocistoscopia) y cuyos síntomas se presentan confinados en la vejiga. Las pacientes diana presentan una edad comprendida entre los 16 años y sin límite de edad máxima. Esta decisión está basada en la edad de inicio de las relaciones sexuales entre los jóvenes españoles[i]. No obstante, también se incluirán las pacientes de 14 y 15 años que sean sexualmente activas.[i] [i] Informe juventud en España 2004, capítulo 6, página 120.

33 Escherichia coli sigue siendo el principal uropatógeno (70-80%) y pone de manifiesto un aumento paulatino y sostenido de su resistencia a algunos de los antibióticos de mayor uso terapéutico en la comunidad. Entre los criterios de elección de un determinado antibiótico para el tratamiento empírico de la infección urinaria no complicada es importante considerar dos aspectos: –Que presente una baja prevalencia de resistencias bacterianas (< 20%) –Que sea de fácil cumplimiento (pauta corta que asegure el mantenimiento de los niveles de asntibiótico durante 3 días) Estas recomendaciones se han priorizado en función de los siguientes criterios: –Sensibilidades de los gérmenes más frecuentemente implicados –Eficacia –Coste y duración del tratamiento RECOMENDACIONES FINALES

34 Tratamiento de 1ª elección: Fosfomicina trometamol en una única monodosis de 3 g Tratamiento de 2ª elección: Sulfametoxazol-Trimetoprim, 800/160 mg/12 horas durante 3 días (en aquellas áreas con resistencias a E. Coli inferior al 20%) Norfloxacino, 400 mg/12 horas durante 3 días Ciprofloxacino, 250 mg/12 horas durante 3 días Amoxicilina-ácido clavulánico, 500/125 mg/8 horas durante 5 días Cefixima, 400 mg/24 horas durante 3 días